Name of court in sending state requesting judicial assistance
Name of plaintiff Docket number V. Name of defendant
Request for international judicial assistance (letter rogatory) (name of the requesting court) presents its compliments to the appropriate judicial authority of (name of receiving state), and requests international judicial assistance to (obtain evidence/effect service of process) to be used in a (civil, criminal, administrative) proceeding before this court in the above captioned matter. A (trial/hearing) on this matter is scheduled at present for (date) in (city, state, country). This court requests the assistance described herein as necessary in the interests of justice. The assistance requested is that the appropriate judicial authority of (name of receiving state) (compel the appear of the below named individuals to give evidence/produce documents) (effect service of process upon the below named individuals). (names of witnesses/persons to be served) (nationality of witnesses/persons to be served) (addressed of witnesses/persons to be served) (description of documents or other evidence to be produced) Facts
(the facts of the case pending before the requesting court should be stated briefly here, including a list of those laws of the sending state which govern the matter pending before the court in the receiving state (questions) (if the request is for evidence, the questions for the witnesses should be listed here). (list any special rights of witnesses pursuant to the laws of the requesting state here). (list any special methods or procedures to be followed). (include request for notification of time and place for examination of witnesses/documents before the court in the receiving state here). Reciprocity The requesting court should include a statement expressing a willingness to provide similar assistance to judicial authorities of the receiving state. Reimbursement for costs The requesting court should include a statement expressing a willingness to reimburse the judicial authorities of the receiving state for costs incurred in executing the requesting court's letters rogatory. Signature of requesting judge Typed name of requesting judge Name of requesting court City, state, country Date (seal of court)